Emergency

Front 1

most important step in managing acute change in mental status of unclear etiology, suicide attempts is to

Back 1

administer antidotes such as naloxone, dextrose, thiamine (due to hypoglycemia or opiate as cause of mental status), oxygen and normal saline all at the same time while checking for toxicology screen

Front 2

when to answer gastric emptying

Back 2

useful only in first hour of overdose...so be sure!

1hr can remove 50% of pills, 2hours-15%, >2hrs is useless

Front 3

what answers are always wrong

Back 3

1. gastric emptying except first 1 hour

2. never use gastric emptying for caustics (acids and alkalis) and altered mental status-aspiration

3. Ipecac is never used in children and patient with altered mental status

4. intubation and lavage if no response to naloxone, thiamine and dextrose within the last 2hrs

Front 4

when to give charcoal

Back 4

when you dont know what to do

it always helps in overdose and does not harm

Front 5

antidote of acetaminophen

Back 5

N-acetyl cysteine (NAC)

Front 6

aspirin overdose

Back 6

bicarbonate to alkalinize the urine

Front 7

benzodiazepines overdose

Back 7

do not give flumazenil, it may precipitate a seizure

Front 8

carbon monoxide poisoning

Back 8

100% OXYGEN, HYPERBARIC IN SOME CASES

Front 9

digoxin overdose

Back 9

digoxin binding antibodies

Front 10

ethylene glycol overdose

Back 10

fomepizole or ethanol

Front 11

methanol poisoning

Back 11

fomepizole or ethanol

Front 12

methemoglobinemia

Back 12

methylene blue

Front 13

neuroleptic malignant syndrome

Back 13

bromocriptine, dantrolene

Front 14

opiates poisoning

Back 14

naloxone

Front 15

organophosphates poisoning

Back 15

atropine, pralidoxime

Front 16

tricyclic antidepressants overdose

Back 16

biocarbonate protects the heart

Front 17

management of acetaminophen poisoning

Back 17

acetaminophen-24hr-vomitng and nausea,

48-72hr- hepatic failure, 10gis toxic, 15g is fatal

give NAC and charcoal to all patients within 24 hours, with high benefit and >24 hr with lower benefit or no therapy

IV NAC for vomiting patients

then check for level of acetaminophen

Front 18

when to use Ipecac

Back 18

at home, immediately after accidental ingestion before coming to the hospital

it requires 15-20mins to work and delays administration of medication

Front 19

what not to do in emergency poisoning

Back 19

1. no cathartics-speeding up GI transit time

2. forced diuresis-cause pulmonary edema

3. gastric emptying of any kind-caustic, acetaminophen, altered mental status

4. whole bowel irrigation only in smuggling, heavy iron ingestion and lithium

Front 20

two most common cause of overdose especially if cause is unknown

Back 20

acetaminophen and aspirin

Front 21

an overdose question with tinnitus is likely

Back 21

aspirin

Front 22

signs of aspirin poisoning

Back 22

1. tinnitus and hyperventilation

2. respiratory alkalosis progressing to metabolic acidosis (from lactate)

3. renal toxicity and altered mental status

4. increased anion gap

5. ARDS

6. interfers with prothrombin time

Front 23

PH balance in aspirin overdose

Back 23

respiratory alkolisis and metabolic acidosis

norm; PH 7.40, pCO2 40, HCO3 24

PH 7.46, pCO2 22, HCO3 16 for example, see that respiratory alkalosis is not a compaensation of metabolic acidosis, since PH is alkalosis and HCO3 is acidosis

give biocarbonate to increase excretion of aspirin

Front 24

cause of primary metabolic acidosis with respiratory alkalosis as compensation

Back 24

CO poisoning, sepsis, uremia and DKA

Front 25

primary respiratory acidosis

Back 25

COPD

Front 26

tricyclic toxicity

Back 26

siezures and arrhythmias leading to death

signs of anticholinergic-dry mouth, constipation and urinary retention

best inital test is ECG-torsades with widening of QRS complex

Rx- sodium bicarbonate to protect the heart from arrhythmia only

Front 27

treatment of caustic ingestion

Back 27

flush out with high volumes of water then perform endoscopy to asses the degree of damage

Front 28

dyspnea, confusion, lightheadedness, MI->death

Back 28

CO poisoning, LV cannot distinguish between anemia and Carboxyhemoglobin (oxygen is picked up but not released to tissues) and lead to stenosis of coronary arteries

give hyperbaric oxygen for severe cases like this (CNS, cardiac, and metabolic acidosis)

100% oxygen for minor cases

Front 29

management of methemoglobinamia (brown blood)

Back 29

oxygen is not picked up at all leading to hypoxia

same symptoms as carboxyhemoglobin (red blood)

causes are nitrates and anesthetics, daapsone and nitroglycerin

normal pO2 on blood gas

test-methemoglobin level

initial therapy-100%oxygen

most effective therapy-methylene blue

Front 30

cyanosis + normal pO2

Back 30

methemoglobinamia

Front 31

signs or nerve gas and organophosphate poisonig (both are absorbed through the skin)

Back 31

salivation, lacrimation, urination, defecation, bronchospasm, secretions

Rx-atropine (blocks acetycholine already released) for nerve gas and organophosphatee for instant relief

pralidoxime (reactivates acetycholinesterase) for prganophosphate

Front 32

managment of digoxin poioning

Back 32

initail-check potassium and EKG-downsloping of ST segment and arrhythmia

most accurate-digoxin levels

treatment-digoxin-binding antibodies

hypokalemia->digoxin toxicity

digoxin toxicity->hyperkalemia

Front 33

signs of lead poisoning

Back 33

wrist drop

sideroblastic anemia

memory loss

lead colic (abdominal pain

ATN

best initial test-protoporphyrin level, most accurate is lead level

best initial for sideroblastic-Prussian blue stain

treatment-succimer orally, EDTA and dimercaprol IV

Front 34

mercury poisoning managment

Back 34

interstitial fibrosis

nervous and jittery, twitchy and hallucination

give succimer and dimercaprol are effective but cannot reverse fibrosis

Front 35

what causes death from snake bite

Back 35

hemolytic toxin-hemolysis and DIC

neurotoxin-respiratory paralysis, ptosis, dysphagia and diplopia

rx-pressure (not tourniquets blocking arterial flow)

immobilization decrease movement of venom and give Antivenin

Front 36

managment and presentation of two types of spider bites

Back 36

black widow- abdominal/muscle pain, lab-hypocalcemia, Rx-calcium, antivenin

brown recluse-local skin necrosis, bullae and blebs, no lab, rx-debridement, steroids and dapsone

all will describe sudden sharp pain like stepping on a nail

Front 37

managemnet of human, dog and cat bite

Back 37

amoxicillin/clavulanate

tetanus vaccination booster if more than 5 years since last injection

Rabies if animal has altered mental status or stray dog

human bites are worse-Eikenella corrodens

dog and cats=pasteurella multocida

Front 38

tratemnt of head trauma

Back 38

first do non contrast CT

1. then if concussion- no specific therapy, home observation, wait 24hr before returning to sports

2. cotussion, no need

3. subdural and epidural (both has lucid interval-loss of consciousness) intubation and hyperventilation(it dec pCO2, which dec cerebral flow, slows herniation and a bridge to surgery), mannitol and drainage

Front 39

indication for stress ulcer prophylaxis with PPIs

Back 39

head trauma

burns

endotracheal intubation

coagulopathy (platelet <50,000 and INR >1.5) with respiratory failure

after surgery of epidural or subdural, start PPIs

Front 40

indication for nimodipine

Back 40

subarachnoid hemorrhage to prevent stroke

Front 41

indication for steroids

Back 41

decrease edema around mass lesions

Front 42

best initial therapy for burns with fire

Back 42

100% oxygen to treat CO poisoning and smoke inhalation

intubation if airway injury and fluid replacement by body surface area (volume loss is second most common cause of death in burn patients)

Front 43

indication for intubation in burns

Back 43

stridor

hoarsness

wheezing

burns inside the nasopharynx or mouth

Front 44

how to replace fluid in burn

Back 44

4ml * %BSA* weight in kg

head=9% BSA

Arms=9% BSA

legs= 9% BSA

chest or back = 18% BSA each

give Ringer lactate or normal saline

Front 45

most common cause of death after burn

Back 45

lung-immediate

infection several days by staphylococcus (prevent with topical silver sulfadiazine antibiotics)

Front 46

management of cardiac arrest

Back 46

1. ensure unresposiveness not syncope or sleeping

2. call for help and 911, activate EMS

3. open the airway;head tilt, chin lift, jaw thrust

4. give rescue breath if not breathing

5. check pulse and start chest compressions if pulseless

Front 47

indication for precordial thump

Back 47

less than 10 minutes of pulselessness, you

'witnessed it happen"

Front 48

cause and best initial treatment for pulselessness

Back 48

1. asystole

2. ventricular fibrillation

3. ventricular tachycardia (VT)

4. pulseless electrical activity (PEA)

Front 49

sign on ECG for hypothermia

Back 49

J waves (where QRS hit ST segment)

patients are usually intoxicated, with low body temperature

Front 50

indication for unsynchronized cardioversion

Back 50

VT and VF only

Front 51

Rx of asystole

Back 51

CPR, epinephrine or vasopresin

Front 52

best initial therapy for Vfib

Back 52

unsynchronized cardioversion (defibrillation) folowed by CPR

then another defibrillation, then epinephrine and another shock

give amiodarone to aid shock to be successful

vfib=shock, drug, CPR, shock, drug, CPR, shock, drug

Front 53

management of Vtach

Back 53

1. if pulseless VT, same as VF

2. hemodynamically stable VT; amiodarone, then lidocaine, then procainamide, if all fail then cardiovert

3. hemodynamically unstable VT; perform electrical cardioversion several times followed by medication-amiodarone, lidocaine, or procainamide

Front 54

when is a patient considered hemodynamically instable

Back 54

chest pain

dyspnea

CHF

hypotension

confusion

Front 55

normal EKG but no pulse

Back 55

PEA

pulseless electrical activity due to low cardiac output

Front 56

causes of PEA

Back 56

1. tamponade

2. tension pneumothorax

3. hypovolemia and hypoglycemia

4. massive pulmonary embolus (PE)

5. hypoxia, hypothermia, metabolic acidosis

6. potassium disorders, either high or low

Front 57

signs of palpitation, dizziness or lightheadedness, exercise intolerance or dyspnea, embolic stroke

Back 57

atrial arrhythmias and most commonly atrial fibrillation

Front 58

flutter vs fibrillation on ECG

Back 58

flutter is regular, fibrillation is irregular

flutter usually goes back into sinus rhythm or deteriorates to fibrillation

Front 59

treatment of Afib

Back 59

rate control and anticoagulants

chronic (lasting >2days)- anticoagulant before synchronized cardioversion

hemodynamically unstable (like that of VT) and acute- immediate synchronized cardioversion

Front 60

treatment of Afib and flutter

Back 60

best initial therapy to control rate with bblockers, CCB (verapamil, diltiazem) or digoxin. when rate is <100bpm, give warfarin, dabigatran or rivaroxaban (use aspirin in low risk patients)

use heparin in presence of current clot in atrium

Front 61

when to use either warfarin, dabigatran rivaroxaban or aspirin

Back 61

when CHADScore is less than 1, use aspirin, if 2 or more use warfarin and others

Front 62

management of palpitation is a healthy hemodynamically stable patient

Back 62

SVT; 160-180/min

best initial step

1. Vagal maneuvers (carotid massage, valsava, drive reflex, ice immersion)

2. Adenosine if vagal maneuvers don't work

3. beta blockers (metoprolol), CCB (diltiazem), or digoxin if adenosine is not effective

Front 63

most liekly diagnosis

SVT alternating with ventriculae tachycardia

SVT that gets worse after diltiazem or digoxin

observing the delta wave on EKG

Back 63

WPW wolff-parkinson-white syndrome

short PR<120 and delta waves

most accurate test is cardiac electrophysiology (EP) tells you where the anatomic defect is

Radiofrequency catheter ablation is curative

use procainamide or amiodarone if also present arrhythmia

Front 64

management of sinus bradycardia

Back 64

ECG to identify cause

asymptomatic, do nothing

symptomatic, give atropine as best initial or pacemaker as most effective, in 2nd (mobitz ii) and 3rd degree AV block even if asymptomatic

symptomatic= hypoperfusion

Front 65

treatment of Vtach in an MI patient

Back 65

angiography for angioplasty or bypass if already on MI medications. correct underlying cause of ischemia

Front 66

test that shows recurrence of Vtach in MI

Back 66

echocardiography

if EF is normal , risk is minimal

MUGA-nuclear ventriculography is most accurate but after using Echo

Front 67

chronic vTach without MI, and unknown etiologies (unprovoked Vtach

Back 67

implantable diefribillation

Front 68

indication of EP

Back 68

to identify source of Vtach

Front 69

clinical features of caustic ingestion

Back 69

features of chemical burn or liquefaction necrosis

laryngeal damage; Hoarseness, stridor

esophageal damage; dysphagia, odynophagia

gastric damage; epigastric pain, bleeding

(hemetemesis, retrosternal or epigastric pain, hyperventilation) presence or absence of oral injury

Front 70

management of caustic ingestion

Back 70

secure airway, breathing, circulation

decontamination; removal of contaminated clothing and visible chemicals; irrigate exposed skin

CXR and AXR for perforation

endoscopy within 24hrs in absence of severe resp. distress or perforation

Front 71

when is charcoal contraindicated

Back 71

in lye (caustic ingestion- sodium or potassium hydroxide). lye causes immediate esophageal errosion and perofration. endoscopy is needed within 24hrs to examine the extent of burn and charcoal will obstruct the view, also emetics are CI

Front 72

complications of caustic ingestion

Back 72

perforation

upper airway compromise

stricture/stenosis within 2-3 weeks

ulcers

cancer

Front 73

signs of anti-histamine poisoning like diphenhydramine

Back 73

diphenhydramine has both anti-histamine and anti-cholinergic effects if taken in excess

(confusion and drowsiness is anti-histamine), dilated pupils, blurred vision, urinary retention, and dry mucosa for anti-cholinergic

treat with physiostigmine

Front 74

nausea, vomiting, abdominal cramps, myalgias, althralgias, diarrhea, restlessness in an IV drug user

Back 74

opiod withdrawal, give methadone only inpatient and when primary disease is medical

Front 75

signs of TCA overdose

Back 75

1. CNS-drowsiness, delirium, coma, seizures, resp. depression

2. CVS- sinus tachy, hypotension, prolonged QT/PR/QRS intervals, V-tach, V-fib

3. anti-cholinergic; dry mouth, blurred vision, dilated pupil, urinary retention, flushing and hyperthermia

Front 76

management of TCA poisoning

Back 76

supllemental oxygen, intubation

IV fluids

activated charcoal for patients within 2 hours of ingestion (unless ileus present)

IV sodium bicarbonate for QRS widening or Ventricular arrhythmia (by removing the depressant action of TCA on sodium channels of myocardium)

Front 77

how does TCA cause cardiac toxicity

Back 77

by inhibiting fast sodium channels in His-Purkinja system and myocardium

QRS interval >100msec an indication of sodium bicarbonate therapy by increasing the extracellular PH and sodium

Front 78

effect of sodium bicarbonate on urine alkalinization

Back 78

to remove salicylate in aspirin overdose

Front 79

when is sodium bicarbonate contraindicated

Back 79

in sepsis and lactic acidosis as it is associated with increased mortality

Front 80

schizophrenic patient with elevated CK, fever, muscle rigidity and diaphoresis is what and treatment

Back 80

neuroleptic malignant syndrome

due to any anti psychotic with dopamine antagonism

treat with dantrolene then dopamine agonist-bromocriptine, amantadine